Uterine Artery Embolization (UAE) vs Laparoscopy vs HIFU€¦ · (laparoscopic and robotic approach) have definite advantage over open myomectomy in terms of less postoperative pain

Uterine Artery Embolization (UAE) vs

Laparoscopy vs HIFU

Thomas J. Vogl, N. NaguibI D I R: Institute of Diagnostic and Interventional Radiology

Goethe University Frankfurt, Germany

Disclosure

Speaker name:

Thomas Vogl

I have the following potential conflicts of interest to report:

Consulting

Employment in industry

Stockholder of a healthcare company

Owner of a healthcare company

Other: travel grant

I do not have any potential conflict of interest

Symptomatic treatment of irregular bleeding: gestagen, oestrogen-gestagen combinations endometrial ablation Mirena Esmya

Hysterectomy

Surgery:

hysteroscopy, laparoscopy, laparotomy

Uterine artery embolization

Focused ultrasound:

MR guided HIFU, US guided HAIFU

Institute of Diagnostic and Interventional Radiology, Goethe University, Frankfurt/Main

Uterine Myoma: Treatment Options


Co-operation with the gynecologist is important

Explain the procedure

Discuss the issue of pregnancy fully

Discuss post-interventional pain

Answer patient’s questions

Remember you are dealing with a benign disease

in young women

UAE: Consent andPreinterventional Counseling

Int. iliac artery

Ant. divisionPost. division

Ext. iliac artery

Common iliac artery

85.5%

7.9%

4.2%

1.8%

0.6%

Naguib, Vogl et al, J Vasc Interv Radiol 2008;

19:1569–1575Institute of Diagnostic and Interventional Radiology, Goethe University, Frankfurt/Main

Uterine Artery Origin

Angle Prediction and Effect onRadiation Exposure

Naguib, Vogl et al, Radiology 2009; 251(3):788-795

IDIR Frankfurt


IDIR Frankfurt IDIR Frankfurt


Usage of the Cephalo-caudal Angulation

Angle Prediction and Effect onRadiation Exposure

Nag

uib

et a

l,R

ad

iolo

gy 2

00

9; 2

51

(3):

78

8-7

95


Size: 500-700 µm or 700-900 µm Rarely: 350-500 µm>300 µm obsolete

Embolization Material Selection



Polyvinyl Alcohol

Bead-Block

Tris-Acryl Gelatin

Microspheres

Embosphere

Gelatin sponge

Gelfoam

Pros

1. Nonresorbable (~Permanant)

2. Precisely calibrated

3. FDA approved for UAE

4. 1st Embolizing material used

by Ravina (conventional)

1. Nonresorbable (~Permanant)

2. Precisely calibrated

3. 1st FDA approved embolizing

material for UAE

4. More deformable and less

tendency to aggregate

1. Not expensive

2. Absorbable within 21 days

(Recanalization after 4

months)1

3. Future pregnancy

Cons

1. Expensive

2. Permanent

1. Expensive

2. Permanent

1. Absorbable ? symptom

recurrence

2. Not calibrated

Barth et al, Invest Radiol 1977; 12:273-280


Prediction of thePredominant Side of Supply

Right Uterine Artery

Left Uterine Artery

Naguib et al, Ultrasound Obstet Gynecol 2012; 40: 452–458

The resistive index can predict the correct side ofpredominant supply in 81.6% of cases

IDIR Frankfurt

IDIR Frankfurt


Effect of Location of Leiomyomaon the Outcome

Naguib, Vogl et al, J Vasc Interv Radiol 2010; 21:490–495



1. Worthington-Kirsch et al. Cardiovasc Intervent Radiol 2011; 34:493-5012. Spies et al. J Vasc Interv Radiol 2004; 15:793-8003. Yu et al. J Vasc Interv Radiol 2011; 22:1229-12354. Abramowitz et al. Radiology. 2009 ; 250(2):482-4875. Katsumori et al. AJR 2002;178:135–1396. Song et al. Minim Invasive Ther Allied Technol. 2013 Dec;22(6):364-71

Polyvinyl Alcohol versus Microspheres:

Similar outcome for both types 1,2

Better clinical outcome and devascularization for Microspheres than polyvinyl

alcohol3,4

Gelfoam versus Polyvinyl alcohol:

Gelatin sponge particles alone is a safe and effective treatment for symptomatic

leiomyomas and that the outcomes bear comparison with PVA 5

Gelatin sponge particles over PVA in terms of improvement of mean bleeding

score and volume reduction rate of dominant fibroid after three months 6


CathetersLeft side:Cobra 4F or 5F

Right side:Cobra 5F with modified Waltman loop1

Sidewinder 5FSidewinder 5F with Microcatheter

1. Pelage et al, Radiology 1999; 210:573-575


Patterns of enhancement

Prognosis


MRI Immediately After UAE

MRI Immediately After UAE

Endometrial-myometrial Ischemia


UAE: Take Home Points

1. You are dealing with a benign tumor in young age

2. MRI before UAE will help select patients

3. Add MRA to detect anatomy and reduce radiation

exposure

4. +/- Doppler to predict predominant side of supply

5. Do not forget the cephalo-caudal angulation option

6. Do not use a size below 300 μm

7. Embosphere > PVA, Gelfoam

8. Use the catheter you can master

9. +/- MRI immediately after UAE for enhancement pattern

10. First follow-up MRI not before 3 months


1. Patients with symptomatic uterine leiomyoma not

responding to medical treatment

2. Clear acoustic pathway of leiomyoma

3. Patient compliance

4. Signal intensity on T2 weighted MRI

5. Contraindications include: pregnancy, pelvic malignancy

or active inflammatory process, extensive scarring or

surgical clips

Patient Selection for HIFU


Peng et al, Medicine (Baltimore) 2015 Apr; 94(13):e650

Factors increasing ablation

difficulty:

1. Retroverted uterus

2. Posterior location of tumor

3. Intramural leiomyoma

Factors influencing the amount of

energy required:

1. Leiomyoma size (large need

less energy)

2. T2 signal intensity

3. Enhancement (progressive

enhancement need more)

4. Acoustic pathway

HIFU: Patient SelectionFactors Affecting Treatment


Zhang et al, Int J Hyperthermia 2015; 31(3):280-284

7,439 Patients treated in 10 centres in China

between 2006 and 2013:

The average treatment time was 84.2±38.8 min (range 30 -

240 min)

The sonication time was 1243.8±725.2 (range 506–2658) s

The technical success rate was 98.4% (7319/7439)

The NPV ratio was 83.1±15.6% (range 25–100%)

The re-intervention rate was less than 10% after 24-month

follow-up

HIFU: Results


Cheung et al, J Ultrasound Med 2013; 32:1353–1358

HIFU: Results


Before HIFU After HIFU

46-year-old patient – Goethe University FFM

HIFU: Results


HIFU should be considered as one of the treatment

options for patients with symptomatic uterine

leiomyoma not responding to medical treatment.

Careful selection of the patient is important to ensure

safe and effective treatment.

The issue of pregnancy should be thoroughly

discussed with patients who haven‘t completed their

family plans.

HIFU: Conclusions


Chitta

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r P

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Opin

Obste

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yn

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l 2

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5 D

ec; 2

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):3

91

-7

Review of nonsurgical/minimally invasive treatments and

open myomectomy for uterine fibroids

FISI 2019

www.fisi-frankfurt.de

20. Frankfurter Interdisziplinäres Symposium für

Innovative Diagnostik und Therapie

Frankfurt/Main, 15 – 16. November 2019

Computertomographie

Before HIFU After HIFU

44-year-old patient – Goethe University FFM

HIFU: Results


Qin et al, Int J Gynaecol Obstet 2012 Jun;117(3):273-7

24 out of 435 patients had unintended pregnancies within 1 year after HIFU

8 desired

pregnancies

14 undesired

pregnancies

2 spontaneous

abortions

14 elective

abortions

One

abortion

7 reached

full-term -

no complications

HIFU and Pregnancy


Review of nonsurgical/minimally invasive treatments and

open myomectomy for uterine fibroids

CONCLUSION:For a woman with symptomatic fibroids who wishes to retain her uterus, apart from medical treatment, various nonsurgical and minimally invasive conservative surgical options are available.Among the nonsurgical options, UAE and, in eligible patients,MRgFUS are more established with availability of larger data and comparative efficacy. Minimally invasive surgeries (laparoscopic and robotic approach) have definite advantage over open myomectomy in terms of less postoperative pain andfaster recovery. A transvaginal approach for radiofrequency ablation as an outpatient procedure seems to be a promising new nonsurgical alternative although it requires more evidence before it can be accepted in day-to-day practice.


Chittawar PB et al, Curr Opin Obstet Gynecol 2015 Dec; 27(6):391-7

Effect of Location of Leiomyomaon the Outcome

IDIR Frankfurt IDIR Frankfurt


IDIR FrankfurtIDIR Frankfurt


MR Angiography BeforeUterine Artery Embolization

Follow-up after 3 months

HIFU: Results


Usage of the Cephalo-caudal Angulation

An additional cephalo-caudal angulation was

required in 15% of patients for the right side.

An additional cephalo-caudal angulation was

required in 30% of patients for the left side.



1. Exclude contraindications

2. Set baseline

3. Select your patients (avoid

leiomyomas >12 cm,

multiplicity is not bad)

IDIR Frankfurt

IDIR Frankfurt

MRI Before Uterine Artery Embolization


Left Uterine Artery RI = 0.64

Right Uterine Artery RI = 0.72

IDIR Frankfurt

IDIR Frankfurt



Failed to embolize one side

Predominant side

Contralateral puncture

Second intervention

Non-predominant side

Wait and see

Second intervention


Institut für Diagnostische und Interventionelle Radiologie, Goethe-Universität, Frankfurt

HIFU

Uterine Artery Embolization (UAE) vs

Laparoscopy vs HIFU

Thomas J. Vogl, N. NaguibI D I R: Institute of Diagnostic and Interventional Radiology

Goethe University Frankfurt, Germany

Documents

Uterine Artery Embolization (UAE) vs Laparoscopy vs HIFU€¦ · (laparoscopic and robotic approach) have definite advantage over open myomectomy in terms of less postoperative pain